A discussion on hemoptysis, classification, approach to management, significant clinical manifestations according to possible causes, management and complications. - lung carxinoma

1. HAEMOPTYSIS : CBD
Joyann Hee
BMS 14091168

2. Case History
• A 66-year-old man presents with a cough that has produced blood-
streaked sputum for the past few months. He brings a container
with approximately 100 mL of blood-tinged sputum produced over
the past 24 hours.
• Associated symptoms include fatigue, loss of appetite and
occasional chest pain.
• He was a heavy smoker of 2 packs per day for 29 years, but stopped
about 20 years ago.
• He has lost 18 kg (20% of TBW) over the past 12 months.
• His medical history is unremarkable and he has not recently
travelled, had fever or night sweats.

3. • Vital signs are within normal limits, and the patient appears
to breathe comfortably, other than intermittent cough.
• Nasal examination demonstrates normal mucosa without
epistaxis. Oropharyngeal examination reveals normal
dentition and mucosa without signs of bleeding or
ulceration.
• The neck is supple and without lymphadenopathy.
Pulmonary examination reveals diffuse inspiratory rales.
Cardiovascular examination is normal except for
tachycardia. Abdominal examination is unremarkable.
• However, the patient does cough up some blood during the
examination. His hemoglobin level is 6.0 g/dL (reference
range 13.5–17.5).

4. Haemoptysis
The expectoration of blood originating from the tracheobronchial tree or the
pulmonary parenchyma.
• Most cases are benign and self-limited; life-threatening haemoptysis is
rare.
• Can be a sign of serious tracheo-pulmonary disease.
• In outpatient primary care, acute respiratory tract infections, asthma,
chronic obstructive pulmonary disease, malignancy, and bronchiectasis
are the most common diagnoses in patients with haemoptysis.
• In comparison, a study of patients with haemoptysis in a tertiary referral
centre showed that bronchiectasis, lung cancer, bronchitis, and
pneumonia account for more than 70% of inpatient diagnoses.

5. • The volume of blood produced has traditionally been used
to differentiate between non-massive and massive
haemoptysis; the cutoff value ranges from 100 to 600 mL of
blood produced in a 24-hour period, the most common
definition is 300 mL, or about 1 cup.
• The bleeding can be from the large or the small pulmonary
vessels. Bleeding from the small vessels is known as diffuse
alveolar haemorrhage, and it characteristically presents as
alveolar infiltrates on chest radiography.
• No cause is identified in 15% to 30% of all cases, even after
extensive evaluation (cryptogenic haemoptysis).

6. Question
What are the initial steps of management and
investigation of this patient?
A 66-year-old man presents with a coughing with
approximately 100 mL of blood-tinged sputum for the
past few months associated with fatigue, loss of appetite
and occasional chest pain.
He was a heavy smoker of 38 packs per day for 29 years.
He has lost 18 kg (20% of TBW) over the past 12 months.
Vital signs are normal. Pulmonary examination reveals
diffuse inspiratory rales. He is anaemic with Hb level of
6.0 g/dL.

7. Initial Management of Haemoptysis
Action Purpose
Monitor the vital parameters Registration of pulse-oximetric oxygen saturation (SpO2),
respiratory and circulatory function (non-invasive blood
pressure measurement [NIBP]); assessment of risk involved in
interventional procedures and medicinal treatment
Give oxygen Improvement of oxygenation
Place the patient with the bleeding side down Prevention of the flow of endobronchial blood into unaffected
lung segments
Sedation/anxiolysis Calming of the patient, facilitation of diagnostic and therapeutic
measures (NB: restriction of breathing activity, ability to
expectorate, ability to cooperate/communicate)
In massive hemoptysis: endotracheal or, if required, unilateral
endobronchial intubation
Maintenance of gas exchange

8. Further Management and Investigations
Method Results of analysis
Clinical chemistry Primary: Inflammation parameters, blood count, coagulation
status
Secondary: Autoimmune diagnosis
Vital parameters (with/without blood gas analysis) Gas exchange and hemodynamics
Chest X-ray (at two levels) Localization of bleeding
Cause of bleeding (pneumonia, lung abscess, bronchial
carcinoma, acute or chronic pulmonary tuberculosis)
Contrast-enhanced multislice computer tomography with CT
angiography
Localization of bleeding
Cause of bleeding
Anatomy and origin of regular or aberrant bronchial arteries
Bronchoscopy Localization of bleeding (right or left lung, lobe, segment, etc.),
cause of bleeding, harvesting of material (microbiology, cytology,
histology)
Treatment as required: keep airways free of blood, administer
vasoconstrictors, tamponade, balloon catheter, laser, argon
plasma coagulation

9. • A chest X-ray was arranged which showed a mass below the right hilum
measuring 4 cm in maximum diameter but no other abnormality in either
lung field or mediastinum.

10. • At bronchoscopy, he was noted to have friable tumour at
the orifice of the right lower lobe, extending into the right
bronchus intermedius. There is mild blood stain but no
active bleeding.
• Biopsy of this showed moderately differentiated squamous
cell carcinoma.
• CT scan of the chest confirmed a 4.6 cm proximal tumour at
the apex of the right lower lobe and in addition, a 2 cm sub-
carinal node.
• Several other small nodes were noted in the mediastinum
but none measured more than 1 cm in diameter. The
remainder of the lung parenchyma was clear and the liver
and adrenal glands appeared normal.

12. Epidemiology and Classification
of Lung Carcinoma
• In the past, SCC was the most frequent cell type in men and among smokers and
adenocarcinoma was the most frequent cell type in women and among never
smokers.
• In recent years, adenocarcinoma was the most common cell type in both in both
men women and in smokers and never smokers.
• In 2014, cancer of the trachea, bronchus and lung accounted for 24.6% of all
cancer mortality in males in Malaysia.
• The smoking prevalence rates in the Malaysian population are 49.2% for male
subjects and 3.5% for female subjects aged 18 years and above. Majority of male
lung cancer patients are smokers.
• The age of peak incidence of lung cancer in Malaysia is the 7th decade of life.
• Lung cancer is diagnosed in never smokers at a younger age (mean age, 54.7 years)
than smokers (mean age, 61.6 years); and this pattern is true for both males and
females.

14. Question
How would you manage this patient?
A 66-year-old man with a history of heavy smoking presents
with a coughing with approximately 100 mL of blood-tinged
sputum for the past few months associated with fatigue, loss of
appetite & weight and occasional chest pain. Pulmonary
examination reveals diffuse inspiratory rales and he is severely
anaemic.
A diagnosis of NSCLC (SCC) in right lung hilar region is
made after X-ray, biopsy, bronchoscopy and CT scan.

15. Treatment for Lung Cancer
• Referral to a pulmonologist, oncologist and chest physiotherapist is
required to manage the patient.
• Treatment for lung cancer depends on the cancer’s specific type, how far it
has spread, and the person’s performance status.
• The common treatments include palliative care, surgery, chemotherapy,
and radiation therapy.
Surgery
• In most cases of early-stage NSCLC, removal of a lobe of lung (lobectomy)
is the surgical treatment of choice.
• Rarely, removal of a whole lung (pneumonectomy) is performed.

16. Radiotherapy and Chemotherapy
• Radiotherapy is often given together with chemotherapy, and may be used with
curative intent in people with NSCLC who are not eligible for surgery.
• Smaller doses of radiation to the chest may be used for symptom control
(palliative radiotherapy).
• Chemotherapy regimen depends on the tumor type. Small-cell lung cancer (SCLC)
is treated primarily with both chemotherapy and radiation. In SCLC, cisplatin and
etoposide are most commonly used.
• In advanced non-small-cell lung cancer (NSCLC), chemotherapy improves survival
and is used as first-line treatment, provided the person is well for the treatment.
• Chemotherapy may be combined with palliative care in the treatment of the
NSCLC. In advanced cases, appropriate chemotherapy improves average survival
over supportive care alone, as well as improving quality of life.

17. • On the basis of the mediastinal lymphadenopathy, he was deemed
inoperable and was referred for an oncological opinion.
• Following discussion of treatment options, it was decided to give him neo-
adjuvant chemotherapy with mitomycin-C (6 mg/m2), ifosfamide (3 g/m2)
and cisplatin (50 mg/m2 , MIC chemotherapy) given on day 1 of a 21 day
cycle.
• He received three cycles, which he tolerated well apart from alopecia and
generalised lethargy, although his third cycle was delayed one week
because of neutropenia.
• His repeat CT scan showed a partial response in the primary tumour
which now measured 2.5 cm in diameter with the sub-carinal node being
1 cm in maximum diameter.
• He went on to receive radical radiotherapy of 5250 cGy in 20 fractions
over 27 days.

18. • The patient remained well and
symptom free for 12 months,
until he returned to the clinic
complaining of increasing
dyspnoea and a 10-day history
of neck swelling.
• On examination, the following
clinical picture is seen.
This patient presented with dyspnea and
elevated P aCO 2 .
A: Plethora of face and neck.
B: Distended jugular veins.
C: Cyanosis of the lips.
D: Right arm and hand massively swollen.
E: Substantial collateral circulation (arrow).

19. Question
What is the condition that the patient is having?
A 66-year-old man with a history of heavy smoking presents with a coughing with
approximately 100 mL of blood-tinged sputum for the past few months associated
with fatigue, loss of appetite & weight and occasional chest pain. Pulmonary
examination reveals diffuse inspiratory rales and he is severely anaemic.
A diagnosis of NSCLC (SCC) in right lung hilar region is made after X-ray, biopsy,
bronchoscopy and CT scan.
12 months later, he returned to the clinic complaining of
increasing dyspnoea and a 10-day history of neck
swelling. He was noted to have face and neck plethora,
distended jugular veins, bluish lips, swollen right arm
and superficial veins on his chest.

21. • Venography confirmed extrinsic compression of the superior vena
cava.
• Under fluoroscopic control, an expandable metal stent was inserted
in to the SVC across the narrowed region resulting in a rapid relief
of his symptoms and signs.
• Unfortunately, after one week, he developed severe low back pain
and a bone scan revealed metastatic disease in several vertebral
levels.
• He received a single fraction of palliative radiotherapy to his lumbar
spine and declined any further chemotherapy.
• Supportive care at home was arranged from the local hospice and
he died six weeks later with liver metastases and
bronchopneumonia.

22. Prognosis
• Overall five- year survival for lung cancer ranges from 10 to
16.8%.
• Outcomes are generally worse in the developing world.
• Prognostic factors in NSCLC include presence of pulmonary
symptoms, large tumor size (>3cm), non-squamous cell
type (histology), degree of spread (stage) and metastases
to multiple lymph nodes, and vascular invasion.
• For people with inoperable disease, outcomes are worse in
those with poor performance status and weight loss more
than 10%.

23. Screening for lung cancer
• For individuals with high risk of developing lung cancer computed
tomography (CT) screening can detect cancer and give a person
options to respond to it in a way that prolongs life.
• This form of screening reduces the chance of death from lung cancer
by an absolute amount of 0.3% (relative amount of 20%).
• High risk people are those age 55-74 who have smoked equivalent of a
pack of cigarettes daily for 30 years including time within the past
years.
• Use of low- dose CT in those who have a total smoking history of 30
pack-years and are between 55 and 80 years old is recommended.
• In smokers, the best prevention of lung cancer is by smoking cessation.

24. References
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Medical Oncology / ESMO. 10. 847-52. 10.1023/A:1008278412614.
3) Menon, M. A., & Saw, H. S. (1979). Lung cancer in Malaysia. Thorax, 34(2), 269–
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